Intraoperative lumbar drainage can prevent cerebrospinal fluid leakage during transsphenoidal surgery for pituitary adenomas: a systematic review and meta-analysis

Intraoperative cerebrospinal fluid leakage and residual tumors in endoscopic transsphenoidal surgery for pituitary adenoma: risk analysis and nomogram development

BACKGROUND

Endoscopic transsphenoidal surgery is the primary method used to treat pituitary adenomas (PAs) at present; however, this technique is associated with certain risks, including cerebrospinal fluid leakage (CFL) and residual tumors (RTs). In this study, we aimed to identify specific risk factors for intraoperative CFL (ioCFL) and postoperative RT in patients with pituitary adenoma and construct a corresponding nomogram for risk assessment.

METHODS

We collected a range of information from 782 patients who underwent endoscopic transsphenoidal PA resection in the Department of Neurosurgery at Beijing Tiantan Hospital between 2019 and 2021. Patients were then randomly assigned to training and validation groups (in a 8:2 ratio) with R software. Univariate and multivariable logistic regression models were then used to screen variables related to ioCFL and RT. These variables were then used to construct a predictive nomogram. Finally, the accuracy of the nomogram was validated by receiver operating characteristic curve (ROC) analysis, calibration plots, and decision curve analysis (DCA).

RESULTS

Univariate and multivariable logistic regression models identified four risk factors for ioCFL (Hardy grade, tumor size, position, and consistency) and five risk factors for RT (operation time, tumor size, consistency, Knosp grade, and primary/recurrence type). The area under the ROC curve (AUC) for the ioCFL risk model was 0.666 and 0.697 for the training and validation groups, respectively. For RT, the AUCs for the two groups were 0.788 and 0.754, respectively. The calibration plots for the ioCFL and RT models showed high calibration quality and DCA analysis yielded excellent efficiency with regards to clinical decision making.

CONCLUSION

Tumor size, growth characteristics, and invasion location were identified as the main factors affecting intraoperative CFL and RT. With our novel nomogram, surgeons can identify high-risk patients according to preoperative and intraoperative tumor performance and reduce the probability of complications.

Cerebrospinal Fluid Diversion for Refractory Intracranial Hypertension in Traumatic Brain Injury: A Single Center Experience

BACKGROUND

Diversion of cerebrospinal fluid (CSF) is a common neurosurgical procedure for control of intracranial pressure (ICP) in the acute phase after traumatic brain injury (TBI), where medical management is insufficient. CSF can be drained via an external ventricular drain (EVD) or, in selected patients, via a lumbar (external lumbar drain [ELD]) drainage catheter. Considerable variability exists in neurosurgical practice on their use.

METHODS

A retrospective service evaluation was completed for patients receiving CSF diversion for ICP control after TBI, from April 2015 to August 2021. Patients were included whom fulfilled local criteria deeming them suitable for either ELD/EVD. Data were extracted from patient notes, including ICP values pre/postdrain insertion and safety data including infection or clinically/radiologically diagnosed tonsillar herniation.

RESULTS

Forty-one patients were retrospectively identified (ELD = 30 and EVD = 11). All patients had parenchymal ICP monitoring. Both modalities affected statistically significant decreases in ICP, with relative reductions at 1, 6, and 24 hour pre/postdrainage (at 24-hour ELD P < 0.0001, EVD P < 0.01). Similar rates of ICP control failure, blockage and leak occurred in both groups. A greater proportion of patients with EVD were treated for CSF infection than with ELD. One event of clinical tonsillar herniation is reported, which may have been in part attributable to ELD overdrainage, but which did not result in adverse outcome.

CONCLUSIONS

The data presented demonstrate that EVD and ELD can be successful in ICP control after TBI, with ELD limited to carefully selected patients with strict drainage protocols. The findings support prospective study to formally determine the relative risk-benefit profiles of CSF drainage modalities in TBI.

Cerebrospinal fluid leakage prevention using the anterior transpetrosal approach with versus without postoperative spinal drainage: an institutional cohort study

The efficacy of spinal drain (SD) placement for cerebrospinal fluid (CSF) leakage prevention after the anterior transpetrosal approach (ATPA) remains unclear. Thus, we aimed to assess whether postoperative SD placement improved postoperative CSF leakage after a skull base reconstruction procedure using a small abdominal fat and pericranial flap and clarify whether bed rest with postoperative SD placement increased the length of hospital stay. This retrospective cohort study included 48 patients who underwent primary surgery using ATPA between August 2011 and February 2022. All cases underwent SD placement preoperatively. First, we evaluated the necessity of SD placement for CSF leakage prevention by comparing the postoperative routine continuous SD placement period to a period in which the SD was removed immediately after surgery. Second, the effects of different SD placement durations were evaluated to understand the adverse effects of SD placement requiring bed rest. No patient with or without postoperative continuous SD placement developed CSF leakage. The median postoperative time to first ambulation was 3 days shorter (P < 0.05), and the length of hospital stay was 7 days shorter (P < 0.05) for patients who underwent SD removal immediately after surgery (2 and 12 days, respectively) than for those who underwent SD removal on postoperative day 1 (5 and 19 days, respectively). This skull base reconstruction technique was effective in preventing CSF leakage in patients undergoing ATPA, and postoperative SD placement was not necessary. Removing the SD immediately after surgery can lead to earlier postoperative ambulation and shorter hospital stay by reducing medical complications and improving functional capacity.

Optimizing Perioperative Care in Transsphenoidal Pituitary Surgery: Considerations for Enhanced Recovery After Surgery

OBJECTIVE

To identify key recommendations for maximizing the efficiency and efficacy of perioperative care in transsphenoidal pituitary surgery.

METHODS

The authors performed a comprehensive literature search of Enhanced Recovery After Surgery protocols implemented for patients undergoing transsphenoidal adenomectomy (TSA); individual recommendations were abstracted, and the evidence base thoroughly reviewed.

RESULTS

The authors identified 19 individual recommendations pertinent to the care of patients undergoing TSA, which were subdivided into preoperative (n=6), intraoperative (n=6), and postoperative (n=7) interventions. Key factors recommended for minimizing length of stay, preventing readmission, and improving patient outcomes included comprehensive patient education, multidisciplinary evaluation, avoidance of routine lumbar drain placement and nasal packing, and rigorous postoperative monitoring of pituitary function and salt-water imbalances. The overall level of evidence for 7/19 (37%) implemented recommendations was found to be low, suggesting a need for continued research in this patient population.

CONCLUSION

Several key interventions should be considered in the development of Enhanced Recovery After Surgery protocols for TSA, which may aid in further decreasing length of stay and promoting positive patient outcomes.

The effect of postoperative early lumbar drainage on delayed fever after cerebellopontine angle tumour surgery: study protocol for a randomized controlled trial

BACKGROUND

Postoperative fever is one of the common complications in neurosurgery, and intracranial aseptic inflammation and infection are important risk factors. Continuous drainage of cerebrospinal fluid (CSF) via lumbar drainage (LD) is often used in the treatment of postoperative intracranial infection or aseptic inflammation. Compared with the previously reported placement of LD after the onset of meningitis symptoms, we designed this randomized controlled trial (RCT) to evaluate the effectiveness and safety of early drainage (1st day postoperation) of CSF using the preset lumbar cistern to prevent delayed fever (fever occurred after the third day postoperation) or reduce its treatment time after cerebellopontine angle (CPA) tumour surgery.

METHODS

Patients suffering from CPA tumours and who underwent resection of the tumour with an intraoperative dura opening time > 4 h are recruited for this study. The study is a 2-arm RCT to compare the early LD group and the no early LD group. Postoperative duration and rate of delayed fever and postoperative length of stay (LOS), as the main outcomes, will be compared in the two groups.

DISCUSSION

Here, we present the study design of a prospective RCT to evaluate the safety and efficacy of using preoperative preset LD to treat or reduce postoperative delayed fever.

TRIAL REGISTRATION

China Clinical Trial Registry ChiCTR2100049057. Registered on July 20, 2021.

External Lumbar Drainage for Refractory Intracranial Hypertension in Traumatic Brain Injury: A Systematic Review

Considerable variation exists in the clinical practice of cerebrospinal fluid diversion for medically refractory intracranial hypertension in patients with acute traumatic brain injury (TBI), which is achievable via lumbar or ventricular drainage. This systematic review sought to compile the available evidence for the efficacy and safety of the use of lumbar drains for intracranial pressure (ICP) control. A systematic review of the literature was performed with the search and data extraction performed by two reviewers independently in duplicate. Nine independent studies were identified, enrolling 230 patients, 159 with TBI. Efficacy for ICP control was observed across all studies, with immediate and sustained effect, reducing medical therapy requirements. Lumbar drainage with medical therapy appears effective when used alone and as an adjunct to ventricular drainage. Safety reporting varied in quality. Clinical or radiological incidents of cerebral herniation (with an unclear relationship to lumbar drainage) were observed in 14/230 patients resulting in one incident of morbidity without adverse patient outcome. The available data is generally poor in quality and volume, but supportive of the efficacy of lumbar drainage for ICP control. Few reports of adverse outcomes are suggestive of, but are insufficient to confirm, the safety of use in the appropriate patient and clinical setting. Further large prospective observational studies are required to generate sufficient support of an acceptable safety profile.

Cerebrospinal Fluid Diversion for Refractory Intracranial Hypertension: A United Kingdom and Ireland Survey on Practice Variation

Introduction Diversion of cerebrospinal fluid (CSF) in a traumatic brain injury (TBI) is an established means for achieving control of intracranial pressure (ICP), aimed at improving intracranial homeostasis. The literature and anecdotal reports suggest a variation in practice between neurosurgical centres internationally, with current guidelines advocating ventricular drainage over lumbar drainage. We sought to establish the current neurosurgical practice in the United Kingdom regarding the methods of ICP control in TBI. Methods A 20-point survey was distributed electronically to British and Irish neurosurgeons after ratification by the Society of British Neurological Surgeons. Questions were directed at the clinician's opinion and experience of lumbar drain usage in patients with TBI: frequency, rationale, and experience of complications. Questions on lumbar drain usage in neurovascular patients were asked for practice comparison. Results Thirty-six responses from 21 neurosurgical centres were returned. Twenty-three per cent (23%) of responders reported using lumbar drains for refractory ICP in TBI patients: six units use lumbar drains and 15 do not. Three units showed partial usage, with mixed "yes/no" responses between consultants. Concerns of tonsillar herniation and familiarity with EVD were commonly given reasons against the usage of lumbar drains. Fifty-six per cent (56%) reported use in neurovascular patients. Conclusion This contemporary practice survey demonstrates mixed practice across the UK and within some centres. Responses and survey feedback demonstrate that the use of lumbar drains in TBI is a polarising topic. The variety of practice between and within neurosurgical units supports consideration of the prospective study of CSF diversion methods for control of refractory ICP in patients with TBI.

Surgical Effects of Resecting Skull Base Tumors Using Pre-operative Multimodal Image Fusion Technology: A Retrospective Study

Objectives

To analyze the surgical effects of resecting skull base tumors using multimodal three-dimensional (3D) image fusion technology in the neurosurgery department and present some typical cases.

Methods

From October 2019 to October 2021, we included 47 consecutive patients with skull base tumors in the Neurosurgery Department at Zhuhai People's Hospital in this study. Pre-operative head computed tomography and magnetic resonance imaging data acquisition was performed using the GE AW workstation software for registration fusion, image fusion, and 3D reconstruction. The surgical approach and surgical plan were designed based on the multimodal 3D image, and the resection rate, complication rate, and operative time of the surgery using the multimodal image fusion technique were analyzed.

Results

The reconstructed multimodal 3D images precisely demonstrated the size, location, and shape of the tumor along with the anatomical relationship between the tumor and surrounding structures, which is consistent with the intraoperative findings. Among 47 patients, 39 patients (78.7%) underwent total resection, 5 (14.9%) underwent subtotal resection, and 3 (6.4%) underwent partial resection. The mean operative time was 4.42 ± 1.32 h. No patient died during the inpatient period. Post-operative complications included 6 cases of cerebrospinal fluid leakage (14.9%), 3 cases of intracranial infection (6.4%), 6 cases of facial paralysis (12.8%), 2 cases of dysphagia (4.3%), and 1 case of diplopia (2.1%), all of which were improved after symptomatic treatment. The application value of pre-operative 3D image fusion technology was evaluated as outstanding in 40 cases (85.1%) and valuable in 7 cases (14.9%).

Conclusions

Pre-operative multimodal image fusion technology can provide valuable visual information in skull base tumor surgery and help neurosurgeons design the surgical incision, choose a more rational surgical approach, and precisely resect the tumor. The multimodal image fusion technique should be strongly recommended for skull base tumor surgery.

Development and Validation of Nomogram to Preoperatively Predict Intraoperative Cerebrospinal Fluid Leakage in Endoscopic Pituitary Surgery: A Retrospective Cohort Study

Background

Pituitary adenomas (PAs) are the most common tumor of the sellar region. PA resection is the preferred treatment for patients with clear indications for surgery. Intraoperative cerebrospinal fluid (iCSF) leakage is a major complication of PA resection surgery. Risk factors for iCSF leakage have been studied previously, but a predictive nomogram has not yet been developed. We constructed a nomogram for preoperative prediction of iCSF leakage in endoscopic pituitary surgery.

Methods

A total of 232 patients who underwent endoscopic PA resection at the Department of Neurosurgery in Jinling Hospital between January of 2018 and October of 2020 were enrolled in this retrospective study. Patients treated by a board-certified neurosurgeon were randomly classified into a training cohort or a validation cohort 1. Patients treated by other qualified neurosurgeons were included in validation cohort 2. A range of demographic, clinical, radiological, and laboratory data were acquired from the medical records. The Least Absolute Shrinkage and Selection Operator (LASSO) algorithm and uni- and multivariate logistic regression were utilized to analyze these features and develop a nomogram model. We used a receiver operating characteristic (ROC) curve and calibration curve to evaluate the predictive performance of the nomogram model.

Results

Variables were comparable between the training cohort and validation cohort 1. Tumor height and albumin were included in the final prediction model. The area under the curve (AUC) of the nomogram model was 0.733, 0.643, and 0.644 in training, validation 1, and validation 2 cohorts, respectively. The calibration curve showed satisfactory homogeneity between the predicted probability and actual observations. Nomogram performance was stable in the subgroup analysis.

Conclusions

Tumor height and albumin were the independent risk factors for iCSF leakage. The prediction model developed in this study is the first nomogram developed as a practical and effective tool to facilitate the preoperative prediction of iCSF leakage in endoscopic pituitary surgery, thus optimizing treatment decisions.

Endoscopic, Endonasal Transsphenoidal Surgery for Tumors of the Sellar and Suprasellar Region: A Monocentric Historical Cohort Study of 369 Patients

BACKGROUND

The endoscopic endonasal transsphenoidal approach (EETA) is an established technique for the resection of a large variety of benign sellar and suprasellar lesions, mostly pituitary adenomas. It has clear advantages over the microscopic approach, like a superior close-up view of the relevant anatomy and the tumor-gland interface, an enlarged working angle, as well as an increased panoramic vision inside the surgical area. We have been performing the EETA for over a decade, and this study will focus on perioperative and postoperative outcomes and complications and their association with the learning curve.

MATERIAL AND METHODS

All patients in our tertiary referral center (n = 369) undergoing an EETA for a lesion of the sellar and suprasellar region between January 1st 2008 and December 31st 2018 were included, and data were retrospectively retrieved from the electronic patient records.

RESULTS

Median follow-up after surgery was 55 months. Pituitary adenomas (n = 322) were the most frequent pathology. Headache (43.4%) and loss of vision (29.3%) were the most common presenting symptoms. Median procedure duration was significantly longer during the initial 5 years (106 versus 79 minutes; p <0.0001), but incidence of peri- and postoperative CSF leaks in the early years was not significantly higher. Knosp grade >2 was associated with perioperative CSF leak (p =0.002), and perioperative CSF leak was associated with postoperative CSF leak (p <0.001). Almost all cases of meningitis were preceded by a postoperative CSF leak. In 22.4% of patients, tumor recurrence required additional therapy. Perioperative (iatrogenic) mortality was 0.8%. The overall hospital stay decreased over time from an average of 7 to 5 days, and the case load increased yearly (p =0.015).

CONCLUSION

The EETA is an excellent technique with complication rates comparable to or even lower than those in large microsurgical series in the literature. EETA has a significant learning curve affecting the procedure duration. Throughout the first 10 years following the transition from the microscopic approach to the EETA in our cohort, the caseload increased and hospital stay was reduced, while no increase in peri- and postoperative complications was observed.